Governance for Better Health

Webinar

Wednesday, 27 June 2012

9 AM to 10 AM EDT

Good Governance from Villages to Parliaments: What Global Health Needs Now

by Jonathan D. Quick, MD, MPH on June 22, 2012

LMG’s Governance Studies

Research questions– What is effective governance in the context of health– What enables it and what hinders it – What are practices of effective governance– How to measure it– What are the gender issues involved – How leadership, management and governance interact to produce

better health outcomes

LMG’s Governance Studies

Targeted literature review Surveys

– 2011 Governance Survey– 2012 Governance Survey

► 477 health leaders, governors and managers form 80 countries

Interviews– 25 key informant interviews from 16 countries

Governance roundtable 18 May 2012– 30 governance thought leaders, experts, practitioners,

donors and CAs

What is effective governance in the context of health

• The governance that leads to both an improvement in health service and the health of individuals and populations

• Predominant themes

Impact on health service and health of people TransparencyAccountabilityParticipationInclusionEthical and moral integrityFocus and visionEfficiency and Equity

What enables it and what hinders it

# Deterrent # Enabler1

Ineffective leadership1 Ethical and moral integrity

2 Corruption 2 Competent leaders governing3

Ineffective management

3 Governing with a definite policy on measurement, data gathering, analysis, and use of information for policy making

4 Inadequate transparency 4 Sound management5

Inadequate accountability5 Adequate financial resources available for

governing

6 Inadequate systems to collect, manage, analyze and use data

6 Openness and transparency

7 Inadequate participation of community/ citizens/ clients/ consumers/ patients

7 Client/community participation in decision making

8Political context

8 Accountability to citizens/clients

9Inadequate checks and balances

9 Governing based on scientific evidence

10 Inadequate financial resources for governance 10 Good Governance in sectors other than health

Defining governing in practical terms

To include To steer To regulate To collaborate To oversee To allocate0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

75% 75%67% 63% 60% 58%

17% 17%21% 26%

25% 29%

6% 5% 8% 8%8%

9%is not a part of governing at all

is a slightly significant part of governing

is a moderately signif-icant part of governing

is a highly significant part of governing

Practices of Effective Governance

Cultivate Accountability

Engage Stakeholders

Set Shared Direction

Steward Resources

Practice Principles

CULTIVATE ACCOUNTABILITY

AccountabilityTransparencyLegal, ethical and moral behavior/Moral capitalAccessibilitySocial justiceOversightLegitimacy

ENGAGE STAKEHOLDERS

ParticipationRepresentationInclusionDiversityGender equityConflict resolution

SET SHARED DIRECTION

Stakeholder alignmentLeadershipManagementAdvocacy

STEWARD RESOURCES

EthicsEfficiencyEffectivenessResourcefulnessFinancial AccountabilityDevelopmentSocial responsibility

Practices Principles Governing actionsCULTIVATE ACCOUNTABILITY Foster a facilitative decision-making environment

AccountabilityTransparencyLegal, ethical and moral behaviorAccessibilitySocial justiceMoral capitalOversightLegitimacy

1. Establish, champion, practice and enforce codes of conduct 2. Embed accountability into the governing institutions 3. Make all reports on finances, activities, and plans available to the public4. Establish oversight and review processes 5. Establish a formal consultation mechanism 6. Sustain a culture of integrity and openness that serves the public interest

ENGAGE STAKEHOLDERS Identify, engage and collaborate with diverse stakeholders

ParticipationRepresentationInclusionDiversityGender equityConflict resolution

1. Empower marginalized voices, including women2. Ensure appropriate participation of key stakeholders 3. Create and maintain a safe space for the sharing of ideas4. Provide an independent conflict resolution mechanism 5. Elicit, and respond to, all forms of feedback 6. Establish alliances for joint action at whole-of-government and whole-of-

society levels

SET SHARED DIRECTION Develop a collective vision of the ‘ideal state’

Stakeholder alignmentLeadershipManagementAdvocacy

1. Oversee the process for developing and implementing a shared action plan 2. Advocate on behalf of stakeholders’ needs and concerns3. Document and disseminate the shared vision of the ‘ideal state.’4. Set up accountability mechanisms for achieving goals 5. Oversee the process of setting goals to reach the ‘ideal state.’6. Oversee the process of realization of the shared goals and the desired

outcomes.STEWARD RESOURCES Steward resources responsibly, building capacity

Financial AccountabilityDevelopmentSocial responsibilityCapacity buildingCountry ownershipEthicsResourcefulnessEfficiencyEffectiveness

1. Champion the acquisition and deployment of resources 2. Protect and invest the resources to serve stakeholders and beneficiaries3. Collect, analyze and use information and evidence for making decisions 4. Build capacity to absorb resources and deliver quality services 5. Use resources in a way that maximizes the health and well-being of the

public

6. Inform and allow the public opportunities to monitor raising, allocation, and use of resources, and realization of the outcomes

GOVERNING PRACTICES

LMG for Results

HSS for Results

Measuring governance

• An overwhelming majority asserted that governance must be measured by the result in terms of improvement in health service and the health.

• A typical comment was — “I think it is fundamental to

be able to show results.”

Process Outcomes Health service attributes

Health outcomesBoth process and outcomesImpact Health impact

Impact beyond health

Transform-ative

16%seek to

transform gender

relations and

promote equity

+++

Responsive

56%clearly

responsive to different

needs based on

gender

++

Aware12%

do not seek to

challenge the status

quo

+

Blind8%

gender does not influence

how decisions are made

0

Exploitative8%

maintain gender

inequalities and

stereotypes

—

Gender in governance

Roles women play in a health system Women in boardrooms or governing positions Women in health workforce Women as users of health care

—“In a situation like that where governance basically is a male thing, then women’s issues are likely to be forgotten…..”

Genderperspective of our key informants

How L+M+G interact to produce better health outcomes

► Leadership, management and governance are interdependent, intricately linked, and reinforce each other.

► There is a clear overlap between the roles of leading, managing, and governing.

► Leaders are critical to the governing process. —Effective leadership is a prerequisite for effective

governance and effective management.

You may access the reportsof our governance studies on the LMG web page of the MSH external site at http://www.msh.org/global-presence/lmg-project.cfm

Over to Karen for how LMG can help enhance governance in public, private, not-for-profit and civil society organizations in partner countries

LMG´s Governance Interventions

June 27, 2012

Karen Johnson Lassner

Who are the potential clients for governance strengthening?

• Public sector: parlimentarians, state legislators, senior MOH officials, state and local health departments, hospital boards, state/province/ municipal/ district/village health boards, and elected councilors

• Multi-sector bodies: CCMs, specific councils for AIDS, RH, TB, women, children & others

• Civil society: CBOs, FBOs,NGOs• Private sector: hospital boards;

company CSR programs• Academia: Schools of medicine,

nursing, pub. health & management

How can LMG help enhance health governance in public, private and not-for-profit institutions in

partner countries?

• Training• Technical Assistance• Knowledge Exchange

LMG Governance Training

Senior Leadership Program

• Who: Teams of 4-6 senior people; from all sectors

• How long: 12-month process with workshops at months 3, 6 & 12

• Content: effective governance practices; strategic problem solving; leadership development; design, implementation & evaluation of a strategy for a priority health problem.

• Certificate: from Yale University

Leadership Development Program Plus (new and improved LDP)

• Who: Managers and teams of health workers who focus on a specific health result

• How long: 6-8 months• Process: Senior Alignment

Meeting chooses priority health area; Technical Team identifies indicators and interventions to address Priority Health Area; Improvement teams meet in 3 workshops to learn L+M+G practices; On-Site Team Meetings to address challenges; 2 Shared Learning Sessions

Effective Board Governance Training Program

• Who: Members of CSO Boards of Directors & key Executive Staff

• How long: One 2-3 day workshop

• Content: L+M+G practices; definition of governance, accountability & transparency; responsibilities of Boards of Directors compared to staff; board operations; risk management; CoI; produces a Governance Enhancement Plan

Effective Board Governance TOT Program

• Who: Trainers who will provide governance training to CSO boards of directors & staff

• How long: One 2-3 day TOT workshop

• Content: L+M+G practices; definition of governance, accountability & transparency; responsibilities of Boards of Directors compared to staff; board operations; risk management; CoI;adult learning techniques

Community Leadership, Management & Governance Training Program

• Who: Community leaders in rural communities

• Process: Five 2-day workshops every 3-4 weeks

• Content: Values-based leadership (personal, family & community); participatory planning; project monitoring; accountability & transparency; reconciliation & forgiveness; conflict resolution; communication; commitment to children; produces a community health project putting leadership & governance skills into practice

Integration of Governance, Leadership, & Management into Pre-Service Curricula

• Who: Curriculum integration teams & support staff

• Process: Three workshops, including a final TOT workshop; includes Pre-Service Guide; can also be delivered virtually

• Content: Local adaptation and integration of action-oriented, practical governance, leadership and management content into the pre-service curricula

Pre-Service Guide provides 3 sample curricula, facilitators’ notes, & resources on logistics & roles and responsibilities within the curriculum integration process.

The Virtual CSO Board Governance Program (VCBG)

• Who: Teams of CSO board members and staff

• Process: Eight-week virtual training program

• Content: role of the board of directors, elements of an effective board of directors, transparency and accountability. By the end of the VCBG, participants develop a draft policy on board transparency and a governance improvement plan.

LMG Governance Technical Assistance

LMG Governance Technical Assistance Areas

• Governance Responsibilities

• Board Member Development

• Governance Performance Assessment

• Governance Monitoring & Information

• Governance and Gender

Adaptations are made in the TA based on the context, i.e. public vs. private sector,

governing individuals (ministers) vs. a governing body, etc.

LMG TA Area 1: Governance Responsibilities

• Role of Governing Body with regard to: Strategic Visioning and Planning, Quality Assurance, Fiscal Vitality, Management, Stakeholder Relations, Interface with Government, Governance Effectiveness

• Board Member Position Description and Performance Expectations

• Role and Array of Committees and Advisory Bodies• Committee Charges and Annual Work Plans• Board Meeting Calendar for 18-month Period

LMG TA Area 1 : Governance Responsibilities (cont.)

• Board Meeting Agendas• Board Chairperson Position Description and

Performance Expectations• Committee Chairperson Descriptions and

Performance Expectations• Board Policy Manual (including Conflict of Interest and

Code of Ethics)• Governance Enhancement Plan for continuous

governance improvement

LMG TA Area 2: Board Member Development

• Board Member Competencies• Competency Mapping Process to Guide Recruitment

and Board Development• Board Member Orientation Program• Board Member Customized Individual Education

Plans• Board Education Plan and Budget• Board Portal for 24/7 access to board materials

LMG TA Area 3: Board Member Development (cont.)

• Board Experience Exchange Process• Digital Reference Library on Governance Concepts &

Practices• eLearning resources• Board Member Mentoring Program

LMG TA Area 3: Governance Performance Assessment

• Governance Overall Risk Assessment• Board Overall Performance Self-Assessment • Governance Overall Performance Self-Assessment Tool• Board Member 360 Assessment• CEO Performance Planning and Assessment• Physician (or other specific HR category) Satisfaction

Survey• Work Force Satisfaction Survey• Middle Managers Performance Assessment• Patient/Client Satisfaction Assessment • Community Perception Survey

LMG TA Area 4: Governance Monitoring & Information

• Design of Board Information System (BIS)

• Governance Dashboard Design and Development

• Development of Governance Performance Indicators & Metrics

LMG TA Area 5: Governance and Gender

What can be done?• Enable more women to

participate in governance and empower them

• Change the governance institutions themselves—making them gender-responsive

• Change mindsets

Purpose: Work with governing boards, institutions and individuals to make them more gender-aware, gender -responsive and gender -transformative, internally and externally for clients

Governance Knowledge Exchange

Knowledge Exchange is getting the right information to the right people at the right time so they can make good decisions.

Sharing, exchanging and using governance information

Inputs Processes Outputs

Knowledge Management Logic Model

Health Systems Performance

Improved

• Access

• Coverage

• Quality

• Efficiency

Individual and Organizational Performance

Improved

• Policy and advocacy informed

• Programs and practice enhanced

• Training and education improved

• Research strengthened

*Project achievements are measured at the initial outcomes level. Intermediate and long-term outcome levels are shown to illustrate how initial outcomes can contribute to these other expected outcomes.

Developed by the KM M&E Working Group (draft: April 27, 2012).

Knowledge Used

• Access • Awareness• Assessment• Adoption• Adaptation

Problem StatementMillions of people die each year due to lack of

information and ill-informed health care services.

Long-Term OutcomeImproved health behaviors and health outcomes

through effective knowledge management

Monitor, Evaluate, and Learn

Initial Outcomes*

Intermediate Outcomes

Procedures

• Best practice guides

•After-Action Reviews

•Mentoring programs

•Communities/ Networks

Services

• Help desk• KM training• Workshops

Products

• Publications• Websites• eLearning

courses • CD-ROMs

KM Culture and CapacityStrengthening

Human andfinancial resources

Data and information

Infra-structure

Equipment

Share

knowledge

Generation

Assessment

Capture Organization

Synthesis

CONNECT, COLLABORATE, BE GENEROUS

Conversation / Activities

Conversation / Activities

Conversation / Activities

Information repository

VersioningInformation

Document process

Facilitation

Adapted from IRC KM Framework

Governance Knowledge Exchange

Sharingknowledge thrupublications

Exchangingknowledgevirtually

Governance Publications

eManager: “Good Governance in Civil Society Organizations”

Governance Publications

eHandbook: HealthSystems in Action

Chapter 3 devoted to Governance

Governance Publications

Guide to Effective CSO Governance

What is it?The Guide is a 34-page compilation of FAQs about CSO governance.

How is the Guide Used?The Guide is used as supplementary training material for face-to-face or virtual training programs on CSO governance. Also serves as a useful Internet resources for persons seeking information on CSO governance.

Virtual Governance Seminars

• LMG can organize virtual seminars of any length on any topic related to governance

• Seminar participants: cross-national, from a single country, from single state or province

LMG Governance Team

Jim Rice

Project Director

jrice@msh.org

Mahesh Shukla

Senior Technical Advisor for Governance

mshukla@msh.org

Karen Johnson Lassner

Governance Officer

klassner@msh.org